What is the role of steroids, such as prednisone (corticosteroid) or methylprednisolone (corticosteroid), in treating severe pneumonia?

Role of Steroids in Severe Community-Acquired Pneumonia

Corticosteroids should be used in patients with severe community-acquired pneumonia (SCAP) who have high inflammatory markers (CRP >150 mg/L) or septic shock, using methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days or prednisone 50 mg daily for those who can take oral medication. 1, 2

Evidence for Corticosteroid Use in Severe CAP

• The Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) recommend corticosteroids for 5-7 days at a daily dose <400 mg IV hydrocortisone or equivalent in hospitalized patients with severe CAP 2
• Corticosteroids can reduce overwhelming inflammation by decreasing cytokines and help with inadequate adrenal response in critically ill patients 1
• Meta-analyses have shown that in patients with severe CAP specifically, corticosteroids are associated with:
  • Significant reduction in mortality (OR = 0.26,95% CI: 0.11–0.64) 1
  • Reduced all-cause mortality, ARDS, and need for invasive mechanical ventilation 1
  • Prevention of ARDS (RR 0.24,95% CI 0.10-0.56) 2

Recommended Dosing and Treatment Protocol

• For severe CAP with elevated inflammatory markers (CRP >150 mg/L):
  • Methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days 1, 3
  • OR Prednisone 50 mg daily for patients who can take oral medication 1, 2
• Treatment should be initiated within 36 hours of hospital admission for maximum benefit 3
• Low-dose corticosteroids (defined as ≤400 mg hydrocortisone equivalent daily) are associated with decreased mortality in severe community-acquired bacterial pneumonia 4

Patient Selection and Timing

• Corticosteroids are most beneficial in:
  • Patients with severe CAP and high inflammatory response (CRP >150 mg/L) 1, 3
  • Patients with septic shock refractory to fluid resuscitation and requiring vasopressors 1
  • Early administration (within 24-36 hours of admission) appears to be more effective than later initiation 3, 5

Cautions and Contraindications

• The IDSA/ATS 2019 guideline gives a conditional recommendation against routine use of adjunctive steroids in all CAP patients, but acknowledges potential benefits in severe cases 1, 2
• Corticosteroids are contraindicated in viral pneumonia, particularly influenza, as they may increase mortality 1, 2
• Potential adverse effects include:
  • Hyperglycemia (RR 1.49,95% CI 1.01-2.19) 2, 3
  • Secondary infections 4
  • Gastrointestinal bleeding and neuropsychiatric disorders 4

Clinical Trial Evidence

• The Torres et al. trial (2015) demonstrated that methylprednisolone reduced treatment failure compared to placebo (13% vs 31%, P = 0.02) in patients with severe CAP and high inflammatory response, although no significant mortality benefit was observed 3
• Recent large trials have shown conflicting results:
  • CAPE COD showed hydrocortisone improved 28-day mortality and reduced risk of intubation when administered within 24 hours of developing severe CAP 5
  • ESCAPe trial did not show differences in 60-day mortality when methylprednisolone was initiated within 72-96 hours of hospital admission 6, 5

Algorithm for Decision-Making

1. Assess CAP severity using validated tools (CURB-65, PSI, or ATS criteria) 1
2. Measure inflammatory markers (particularly CRP) 1, 3
3. If severe CAP (requiring ICU admission) AND either:
   • CRP >150 mg/L, OR
   • Septic shock requiring vasopressors
4. Then initiate corticosteroids within 36 hours of admission:
   • Methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days, OR
   • Prednisone 50 mg daily for 5 days if oral intake is possible 1, 2
5. Monitor for hyperglycemia and other adverse effects 2, 4
6. Do NOT use corticosteroids if influenza pneumonia is confirmed or strongly suspected 1, 2